Failure to Notify and Monitor After Resident Fall Resulting in Fracture
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall resulting in a fracture. The staff did not notify the resident's family or physician in a timely manner following the fall with possible injury. Documentation of the initial assessment and ongoing fall monitoring, including neurological checks, was not completed as required. The facility also lacked a policy and procedure related to falls, fall documentation, and fall notifications. The resident involved had diagnoses including Alzheimer's disease, muscle weakness, high blood pressure, and respiratory failure, and required supervision and a walker for mobility. After the fall, the resident was found on the floor complaining of pain in the left hip and was assisted back to bed by staff. The LPN on duty did not document a full assessment, including baseline neurological checks, and did not notify the physician or the resident's family at the time of the incident. Vital signs were reportedly obtained but not documented, and the nurse did not initiate required fall monitoring or incident reporting procedures. Subsequent shifts identified the resident's continued pain and loss of independence with mobility, leading to an x-ray that revealed a probable fracture. Only then were the physician and family notified, and the resident was transferred to the hospital. Interviews with staff and leadership confirmed that the expected process for falls was not followed, including assessment, documentation, notification, and monitoring. The deficiency was further compounded by the absence of a facility policy on falls and related documentation.